How to Make Video Therapy As Good as the IRL Version

More and more healthcare is happening online, which means both providers and patients are figuring out how to interact through screens without sacrificing quality of care. The learning curve can be especially steep in therapy, where a comfortable atmosphere and a strong personal connection are important components of effective treatment. But it’s entirely possible to have a productive, non-awkward session without being in the same room.

We asked five therapists how they connect with patients during video visits, and what patients can do on their ends to make sure teletherapy is a worthwhile experience. Here’s what they had to say.

I recommend a few things to my patients to ensure a productive teletherapy session, including a pre-therapy routine. Similar to the walk to therapy, I suggest using a few minutes to create movement as a way to prepare for the movement of the emotions to come. I also encourage my patients to turn off messaging or any other pop-ups that could take their attention away from therapy. Some patients put sticky notes on their own screen so their own facial expressions don’t distract them.

It’s also important to create room for a new type of experience. Many people expect a similar feeling as they had in the physical space and then can pressure it to feel the same. However, teletherapy should be a “new” experience which offers a new process and way of connecting.

In order to have a really positive and productive session, I have changed the format of my teletherapy appointments so they are a bit different from the usual, in-person appointments. Since we do just about everything in our rooms now, including working, parenting, sleeping and now therapy, I have decided to start each session with a guided meditation. I meditate for five minutes with all my patients as a way to introduce and “come into” our therapeutic space together. Although this is something I generally don’t do in person, it felt necessary to create a new space together and be more intentional on the way in which we build our new space and the new type of work we are doing together.

Rounds

I remind my patients to mentally treat telehealth sessions like they would any other therapy session. Because we are all juggling so many competing responsibilities from home, remember to schedule it into a phone or paper calendar. Second, I prompt patients before we start telehealth sessions to find a consistent spot in their home that feels private, comfortable and convenient. If they have children, we discuss making sure to coordinate care with their partners or other caregivers to ensure privacy and minimal distractions. I get creative with some who are unable to find a spot inside their homes. A few have found it easiest and most helpful to sit in their car.

I find having patients practice a brief moment of mindfulness, via breath work, body scanning and other self-soothing tools, helps them feel grounded and able to engage more quickly in our sessions. We briefly check in regarding how they are coping that week, and we discuss what they need from our session that day. Though COVID-19 can be a focus for therapy, I keep them focused on the goals we came up with together before the pandemic.

I also name the elephant in the room: Telehealth is different from face-to-face sessions, and it can even be slightly awkward at first. I allow my clients to process their feelings about utilizing telehealth, and I address any concerns they have about it in our first telehealth session. Often I find that patients need me to validate the loss of not having the same in-person connection they are used to. Though it is not perfect, telehealth is “good enough” and far better than going without mental health support amid such collective uncertainty and anxiety. Thankfully, the adjustment to sessions via video is fairly fast.

As sessions come to a close, I have my patients name one thing they took away from our time together, or one thing they are looking forward to in the week. This has been a positive way to feel productive and focused with our time.

Therapy is often seen as a form of treatment where the therapist is assumed to be the primary catalyst to the client’s change, which could not be further from the truth. Just as the client sets the tone in traditional face-to-face therapy, they have that same ability to set the tone when engaging in teletherapy.

One way that the client can make teletherapy beneficial is making themselves available for a certain time and day that they know will be a reliable time slot with minimal interruption. Unnecessary distractions delay the therapy process and may delay client’s from expressing themselves fully and genuinely. For clients who are new to teletherapy, it would benefit them to utilize the intake session or the first session to ask questions freely in order to feel as comfortable as possible.

For me, the first and most important element in making teletherapy beneficial is being patient. Therapy is about allowing the client to feel comfortable discussing the topics that brought them into therapy in the first place. This task is to be treated carefully in the traditional face-to-face session. Accomplishing this task via teletherapy requires that much more care and consideration for the client’s needs.

Another way the therapist can make sessions beneficial is simply dressing the part. While sessions are usually conducted from the comfort of my own home, it’s important to dress in a manner that creates a sense of professionalism to help build trust between client and therapist.

One aspect of teletherapy that should be considered by both client and therapist is reliable internet connection and platform. Lighting is also important for both parties. A well-lit room will not only increase visibly on both ends but ease potential anxiety as both are able to see one another clearly, which improves overall rapport.

Studies are showing that teletherapy can be just as productive and beneficial as in-person therapy. That being said, it is different seeing a clinician online versus in person, so know that it won’t feel quite the same if you’ve been seeing your therapist in person and are now transitioning online. There are some things you can do to make sure you have a helpful and successful session online.

First, find a space in your house that’s private and comfortable for you, and bring in any item you may need such as a blanket or tissues; even a pet can be calming. Make sure you have a strong internet connection and good lighting so your therapist can see you well. It can also be helpful to use headphones so you don’t hear an echo on your video call. Be open and honest with your therapist about how you’re feeling and the things you’re comfortable with and things that might feel a little strange or different to you now. Also, try to keep an open mind about trying something new, as this might not be your first choice for your sessions, but it might actually come to be something you prefer to do long-term given the convenience and your comfort level being in your own space for your sessions.

To ensure I’m in a good mental space to help my clients, I do a five-minute quiet meditation, journaling and exercise before my first therapy session in the morning. I have a home office that I use for all my sessions, so it’s a consistent space for all of us. I use an ethernet cable to connect my computer directly to my modem, which helps with the overall connection. I also use headphones and have two eye-protection LED desk lamps for great lighting during my sessions and to protect my eyes. On screen, I’m the same as in person. I use empathy, validation and humor to connect with my clients from the start. If they seem uncomfortable about any part of their online sessions, we talk about it and address it openly.

There are a few things clients can do to make telehealth more useful for them. They can think ahead of time about where they’ll find privacy to talk. Clients should feel free to contact the therapist if a change in appointment time would help you find the privacy to talk openly. Get in touch with us before the session if you have any questions about how telehealth works and if your insurance will cover it.

Clients can also ask themselves how coronavirus is changing what they need from therapy. Maybe they were talking about anxiety, but now loneliness is the new priority. Maybe they were working on opening up about feelings, but now they’ve got more feelings than they know what to do with and need specific skills for handling strong emotions. If they’ll be logging in from home, think about both privacy and the opportunities. Would it be meaningful to show the therapist some art projects or introduce the therapist to their pet? If a couples or family session would help, talk to the therapist about that opportunity while the family is together in the same space and coordinating schedules will be easier.

The therapist can look for ways to help clients connect by role-modeling online socializing in real time and helping clients talk about thoughts and feelings at the exact moment thoughts and feelings are happening, instead of talking about things that happened in the past week. The therapist is going through a lot too, and having a lot of emotions, so they can role-model those coping skills and be in the moment with clients in a way that wasn’t possible before. The two of you can work on setting and respecting boundaries by talking about what it’s like to see into each other’s homes and to know something about how the therapist is coping. Session time shouldn’t be spent on the therapist’s issues, but on learning from them about how to handle new challenges.

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For people with irritable bowel syndrome, it’s common to hear that symptoms such as cramping, alternating diarrhea and constipation, and bloating are “all in their head.” In the case of IBS, there’s actually some truth to this.

It’s not that their symptoms don’t exist. IBS is a very real disorder, and managing its physical toll often becomes an all-consuming effort. The litany of concerns that accompany so many activities — always scouting the closest bathroom, making sure you can reach it in time, farting in public — keeps many people with IBS from having a social life.

Yet according to some experts, IBS is not solely about what’s going on in the digestive system; rather, the brain exacerbates the condition. “IBS is a disorder of brain-gut dysregulation,” explains GI psychologist Sarah Kinsinger, who is also co-chair of the psychogastroenterology section of the Rome Foundation. Accordingly, addressing the “brain” side of IBS through cognitive behavioral therapy with a trained psychologist may help decrease both the anxiety that’s often associated with the disorder and its physical symptoms.

“CBT really should be the first-line treatment for people with IBS. It’s the treatment with by far the most empirical support, and when done well, it can be curative,” says Melissa Hunt, associate director of clinical training in the psychology department at the University of Pennsylvania.

In a series of trialspublished last year, researchers in the UK compared the standard treatment for IBS (typically diet and lifestyle modifications and/or medication) with eight sessions of CBT delivered over the phone or online. Before and after the trials, participants answered questionnaires designed to measure their anxiety, depression and ability to cope with their illness. Two years after the trials, 71 percent of the phone-CBT group and 63 percent of the online-CBT group reported clinically significant changes in their IBS symptoms. Meanwhile, less than half of the standard-treatment group reported such an improvement. Those who did CBT also exhibited lower levels of anxiety and depression and higher coping ability than other participants.

In an earlier meta-analysis (a study of studies), published in 2018 in the Journal of Gastrointestinal and Liver Diseases, a different team of researchers also found that CBT appeared to reduce both psychosocial distress and the severity of IBS symptoms, with a greater effect on the physical symptoms than on the mental ones.

Explainers

The brain-gut connection

How this happens is not completely clear at this point, but it’s believed to have something to do with how the gut and brain communicate.

“IBS is thought to be a disorder of centralized pain processing,” Hunt explains. “There is miscommunication between the pain centers in the brain and the nerves in the gut. In people with IBS, pain signaling gets inappropriately amplified.” Discomfort that wouldn’t even register in the majority of people feels like being stabbed in the gut to a person with IBS. “The best way to address that is to find ways to help reduce pain signaling, and that’s with a psychologist,” Hunt says.

CBT for IBS entails learning relaxation techniques, such as diaphragmatic breathing and progressive muscle relaxation, which help reduce the “volume” of the pain signals by activating the parasympathetic nervous system, i.e., the body’s “rest and digest” response. “This can also lead to increased blood flow and oxygen to the digestive system, which helps the GI tract to function in a more rhythmic way,” says Kinsinger, who is also an associate professor at Chicago’s Loyola University Medical Center.

CBT also involves thought restructuring. IBS can cause a cycle of worry: Worrying about symptoms leads to being hyperfocused on the slightest hint of any symptom, which increases anxiety, which aggravates symptoms. People with IBS also often catastrophize, meaning they assume the worst will happen (“If I have an accident at work, I’ll get fired and never get another job”), develop social anxiety and become withdrawn. CBT addresses these issues by shifting attention away from IBS symptoms and using exposure therapy to help people gradually engage in more activities outside their homes.

Additionally, using CBT, people with IBS learn to identify and change dysfunctional ways of thinking. For example, consider someone with school-aged children who asks their spouse to attend all school functions because they’re afraid of farting in a room with other parents, which would inevitably cause humiliation and might even make people think they’re disgusting A therapist might ask them how often they notice bodily noises from other people to help them realize that we’re a lot more cognizant of our own bodily functions than other people are. “In other words, we identify the catastrophic beliefs and then search for evidence supporting them or not,” Hunt says.

CBT is a skills-based, goal-oriented approach to treating mental disorders that emerged in the mid-20th century. All CBT programs share the same underlying goal of helping patients identify and modify negative or unhelpful thought patterns and behaviors. “It teaches patients techniques that they can then implement on their own.” says Kinsinger. “It can be done pretty efficiently, depending how motivated and receptive one is to learning these skills.” But over time, customized versions of CBT have been developed for specific conditions including insomnia, schizophrenia and IBS. Different versions of CBT use different techniques, such as role-playing, exposure therapy and relaxation exercises, and vary in length. On average, CBT for IBS lasts between 4 and 10 sessions in total.

Jeffrey Lackner, professor and chief of the division of behavioral medicine at the University at Buffalo, SUNY, says their program is structured like a course: “You learn a specific skill to manage your GI symptoms, process information differently or respond to stress in a less extreme way. Then you practice that skill in session before using it in the real world.” Often therapists also give patients homework to fine-tune the skills they learn. They come out of CBT with a toolbox of techniques to manage the day-to-day burden of IBS.

Some people with IBS do CBT on their own, using self-help books, online materials or apps without ever seeing a therapist. “Not many psychologists are trained to treat GI disorders specifically, so physicians don’t often have anyone to refer patients to,” Kinsinger says. The Rome Foundation trains psychologists and maintains a directory of gastrointestinal psychologists, but if someone can’t find a provider in their area, Hunt and Kinsinger recommend looking for a psychologist who’s trained in CBT and has experience treating chronic pain, panic disorders or anxiety.

Reducing sensations vs. reducing sensitivity

Not everyone is fully on board with CBT for IBS. One 2018 review study found “insufficient evidence to demonstrate the effectiveness of online CBT to manage mental and physical outcomes in gastrointestinal diseases” including IBS. A different 2018 review concluded that although psychological treatments for IBS appear to help in clinical trials, it’s unclear if they work in other settings and which treatments — such as CBT, mindfulness-based stress reduction and guided affective imagery — are most effective.

IBS is a complex problem, and some doctors prefer to integrate CBT with other treatments. But “by the time we see them,” Lackner says, “many of our patients have found that the medical treatments have not provided adequate symptom relief.”

Some IBS patients also find thetraditional approaches too hard to stick with. The most commonly prescribed treatment is a “low-FODMAP” diet, which requires giving up all dairy and legumes, plus many grains, fruits and vegetables. “Some trials show that even if the diet reduces or eliminates GI symptoms, it doesn’t improve quality of life because it’s crazy restrictive,” Lackner points out.

“With IBS, the nerve endings in the gut have become hypersensitized, and the brain magnifies those signals in the gut,” Hunt says. “The low-FODMAP diet tries to reduce the sensations, whereas CBT reduces the hypersensitivity. When you turn down the volume on the sensations, then you can eat whatever you want.”

Whether CBT helps with this brain-gut dysregulation, addresses distorted thinking and anxiety, or increases confidence in a person’s ability to manage gastrointestinal symptoms — or all of the above — it’s helped people with IBS resume parts of their life they’d put on hold.

Brittany Risher is a writer, editor and digital strategist specializing in health and lifestyle content. She's written for publications including Men's Health, Women's Health, Self and Yoga Journal.

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